Healthcare Provider Details

I. General information

NPI: 1427773498
Provider Name (Legal Business Name): BUILT BY WIKOFF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 E MINNESOTA ST
INDIANAPOLIS IN
46203-3920
US

IV. Provider business mailing address

928 E MINNESOTA ST
INDIANAPOLIS IN
46203-3920
US

V. Phone/Fax

Practice location:
  • Phone: 317-999-7853
  • Fax:
Mailing address:
  • Phone: 317-999-7853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY EAVES
Title or Position: CLINICIAN
Credential: RD
Phone: 317-999-7853